T. Thubert

Combined Conservative Surgical and Medical Treatment of a Uterocutaneous Fistula

Uterocutaneous fistula is a rare complication that may follow cesarean section. Herein is described a rare case of uterocutaneous fistula. The patient, a 28-year-old woman with a history of American Society for Reproductive Medicine stage IV endometriosis (Douglas pouch obliteration), underwent a cesarean section at 25 weeks of gestation (twin pregnancy). Postoperatively, the patient returned to the emergency service because of the appearance of pus through the cesarean section abdominal scar, and was treated for a subcutaneous abscess. Because drainage continued, the presence of a uterocutaneous fistula was suspected. Magnetic resonance imaging confirmed this diagnosis. Hysteroscopy clearly revealed the uterine neck of the fistula tract. Leuprolide acetate (gonadotropin-releasing hormone agonist) deposit suspension was administered subcutaneously monthly for 6 months. Surgery via laparoscopy and laparotomy was performed. This combined medical and conservative surgical treatment was successful. At 6-month follow-up, hysteroscopy revealed a normal uterine cavity. We conclude that magnetic resonance imaging and hysteroscopy are helpful in diagnosis of uterocutaneous fistula. Conservative surgical treatment associated with medical therapy can be an efficient procedure in women who desire subsequent pregnancies.

Satisfaction, quality of life and lumbar pain following laparoscopic sacrocolpopexy: suture vs. tackers

OBJECTIVE To compare the operative results and rate of complications, in particular dorsolumbar pain, following laparoscopic sacrocolpopexy (LS) using sutures or tackers. STUDY DESIGN A case-control study: LS using tackers (n=35, tacker group) compared with LS using sutures (n=65, suture group). In addition to clinical evaluation of prolapse, all patients were evaluated for urinary incontinence (ICIQ-SF), dorsolumbar pain, overall quality of life (SF-36 score), and overall improvement in symptoms (PGI-I), one year after LS. RESULTS The patient characteristics (age, initial stage of prolapse,…) were comparable in the two groups, as was operating time (240 vs. 210min, p=0.18). There was no significant between-group difference in terms of anatomical correction (median post-operative ICS stage: 0 in both groups, p=0.26) or post-operative complication rates. The incidence of de novo low back pain appearing after LS was equivalent in both groups (50% vs. 25%, in the tacker and suture groups, respectively, p=0.11). However, there was a significant difference in lumbar pain intensity evaluated using the visual analog scale (4 (IQR 0-6.5) vs. 0 (IQR 0-4) in the tacker and suture groups, respectively; p=0.01), and in post-operative quality of life, which was better in patients in the suture group according to all the questionnaires. CONCLUSION Our study suggests that the use of tackers for prosthesis fixation to the promontory does not increase the incidence of post-operative dorsolumbar pain, but may increase its intensity and decrease quality of life.

Comparison of functional outcomes with purely laparoscopic sacrocolpopexy and robot-assisted sacrocolpopexy in obese women.

OBJECTIVE To compare the functional outcomes and complication rates following laparoscopic sacrocolpopexy (LS) with those occurring in robot-assisted laparoscopic sacrocolpopexy (RALSCP) in obese women. PATIENTS AND METHODS A comparative retrospective multicentre study was made, involving 39 obese women (BMI≥30 kg/m2) who underwent LS, and 17 obese women who underwent RASCLP. The operative parameters (length of operation, associated procedures, complication rate and length of hospitalization) and the objective and subjective results were evaluated at 12 months follow-up. RESULTS The median (IQR) BMI was 30.5 kg/m2 (30-32) in the LS group vs 31.6 kg/m2 (30-34) in the RALSCP group (P=0.402). The anatomical results were comparable in both groups (LS vs RALSCP): post-operative stage of prolapse (POP-Q-ICS): stage 0-1: 34/39 (88%) vs 16/17 (94.1%), P=0.7; stage 2: 4/39 (10%) vs 0/17 (0%), P=0.7; stage 3-4: 1/39 (2%) vs 1/17 (5.9%), P=0.7. The complication rate was similar in both groups (LS vs RALSCP): bladder injury 2.5% (1/39) vs 0% (0/17), P=0.6, laparoconversion 5.1% (2/39) vs 5.9% (1/17), P=0.5. The overall reoperation rate was (LS vs RALSCP): 18% (7/39) vs 5.9% (1/17), P=0.4. CONCLUSION Laparoscopic sacrocolpopexy and robot-assisted laparoscopic sacrocolpopexy have equal results in obese women. The complication rates and outcomes appear to be similar in both groups of obese women. LEVEL OF EVIDENCE 3.

Delivery induced intraperitoneal rupture of a cystic ovarian teratoma and associated chronic chemical peritonitis.

Intraperitoneal rupture of cystic ovarian teratoma is a rare complication. We report a case in a 29-year-old female, with increased abdominal circumference 2 months after vaginal delivery. MRI/CT raised this diagnosis associated to chemical peritonitis. A malignant ovarian mass with peritoneal carcinomatosis was excluded. Laparoscopic oophorectomy was performed and histologic analysis confirmed imaging findings. This case demonstrates the interest of imaging before surgery in pelvic masses to avoid misdiagnosing and to provide adequate treatment.

Diffusion des recommandations pour la pratique clinique concernant l'incontinence urinaire de la femme

OBJECTIVE Recommendations for good clinical practice concerning the treatment of urinary incontinence in women are available from the HAS (Haute Autorité de santé or French National Authority for Health), the Collège national des gynécologues obstétriciens français (French national college of gynaecologists and obstetricians) and Association française des urologues (French association of urologists). We wanted to conduct the first investigation of these recommendations to primary care physicians (GPs) and gynaecologists in the cities located in the same area of health. METHODS A questionnaire was sent to GPs and gynaecologists (French administrative divisions 78 and 92), with questions on the recommendations, as well as the methods of dissemination of these recommendations. Response rate: 22%. RESULTS A total of 72 questionnaires were usable from 51 (71%) GPs and 21 (29%) gynaecologists. Of these, 76% of gynecologists and 47% of GPs were aware of recommendations from the HAS for clinical practice for urinary incontinence in women (P=0.04). Only 56% of doctors prescribed a urinalysis (dipstick or bacteriological urinalysis) and evaluated the residual urine in women seeking care for symptoms of urinary incontinence. Training for one or two days was the most desirable/popular method of dissemination of the recommendations (30 out of 72 doctors), followed by journals such as Prescrire, then the mailing and forms provided by the HAS, especially when combined with office visits from a representative of the HAS. CONCLUSION This study provided an interesting perspective on the knowledge, dissemination and application of recommendations for good clinical practice concerning urinary incontinence in women.

Posterior vaginal wall pull down maneuver: a clinical test to diagnose intrinsic sphincter deficiency in women suffering from genuine urinary stress incontinence.

To assess the predictive value of a simple clinical test (posterior vaginal wall pull down maneuver) in the diagnosis of intrinsic sphincter deficiency.

Outcomes of laparoscopic sacropexy in women over 70: A comparative study

OBJECTIVE Precise data are lacking concerning laparoscopic sacropexy in the elderly population. The purpose of this study was to compare the outcomes and complications associated with laparoscopic sacropexy (colpopexy or hysteropexy) in women aged under 70 and 70 or over. STUDY DESIGN Retrospective review of data on patients who underwent laparoscopic sacropexy in two tertiary centers. Peri- and postoperative complications were recorded and described using the IUGA classification. Surgery was considered successful if the patient was symptomatically satisfied or very satisfied and if the POP-Q (Pelvic Organ Prolapse-Quantification) stage score at the follow-up visit was below stage 2 for all compartments. RESULTS Among the 191 women studied, 47 (24.6%) were aged 70 or more. According to the ICS/IUGA classification of POP complications, perioperative and postoperative complication rates were similar in the older versus younger groups (bladder injuries (0 vs. 1.39%, p=1) (4A T1 S2), rectal injuries (0% vs. 0.69%, p=1) (5BT1S5), vaginal injuries (2.13% vs. 0%, p=0.246) (2A T1 S1)). No laparotomy conversion was required in either group. At two months of follow-up, the success rate was 97.9% and 95.1% in the older and younger groups, respectively (p=0.68). At 24 months of follow-up, the overall reoperation rate was 12.8% for the older group versus 11.8% in the younger group (p=0.80). CONCLUSIONS Our findings suggest that laparoscopic sacropexy is a valid option in elderly women presenting with genital prolapse.

Outcomes associated with the use of midurethral slings for stress incontinence surgery according to the type of hospitalization

To evaluate the influence of type of hospitalization on outcomes of stress urinary incontinence (SUI) surgery using a midurethral sling procedure.

Female perineal diseases: spectrum of imaging findings

Abstract The female perineum, which is divided into the anterior urogenital triangle and the posterior anal triangle, is a surface structure often overlooked. Female perineal diseases may present with nonspecific clinical signs due to its close anatomical relationship between the different compartments. Diagnosis of the origin of a perineal disorder may also be a difficult problem encountered in pelvi-perineal imaging. Therefore, a precise knowledge of the female perineal anatomy and the associated disease processes is essential to radiologists, pathologists, and surgeons alike who are involved in the evaluation of the patient who presents with a perineal mass. Cross-sectional imaging plays a crucial role for proper management. Due to the robust contrast resolution of MR, MR imaging is the modality of choice for evaluation of the extent of a complex perineal lesion, its relationship to the adjacent structures. It has a greater sensitivity and specificity for the diagnosis than the other non-invasive imaging techniques and is helpful in guidance for surgical planning. The purpose of this article is to highlight the spectrum of imaging findings of female perineal diseases.

Réintervention par bandelette sous-urétrale pour récidive d’incontinence urinaire d’effort féminine après une première bandelette sous-urétrale

INTRODUCTION There are few data concerning the results of the treatment of recurrent stress urinary incontinence (SUI) after redo mid-urethral sling (MUS) procedure. METHODS Retrospective study concerning 34 patients presenting with recurrent SUI following the placement of a first MUS procedure and who have undergone a second MUS procedure. Results were evaluated objectively (cough stress test) and subjectively using international consultation on incontinence questionnaire-short form (ICIQ-SF). RESULTS The surgical technique for the placement of the first MUS was a retropubic approach in seven (20.5%) cases and a transobturator approach in 27 (79.5%) cases. Concerning the redo MUS procedure, a retropubic procedure was performed in 25 (73.5%) patients and a transobturator procedure in nine (26.5%) patients. Among the 34 patients, 32 (94%) were re-examined at 2 months follow-up, and contacted through telephone after 1-year follow-up. Post-operatively, the cough stress test revealed no urine leakage in 27/32 (84%) patients. Median follow-up was 15.5 months. ICIQ-SF score was 0 (complete continence) in 19/32 (59%) patients; between 4 and 12 in 11/32 (34%) and between 13 and 20 in 2/32 (6%) patients. A bladder injury was diagnosed during the surgical procedure in two patients. A reintervention was required in 2/34 (5%) patients because of postoperative urinary retention or bladder outlet obstruction. A partial sling resection was required in 2/34 (5%) patients because of vaginal exposure of the synthetic sling. CONCLUSION In this study, redo MUS procedure was associated with good functional results despite a high rate of complications.